<div class="container">
	<div class="content">
		<form class="well" style="padding: 50px;">
			<div class="clearfix">
				<label>Avatar</label>
				<div class="input" style="display: block;">
					<img style="display: inline-block" src="http://placehold.it/90x90"><br/>
		           	<input class="input-file" id="fileInput" name="fileInput" type="file">
		        </div>
	        </div>
	       	<div class="clearfix">
				<label>Nom : </label>
				<div class="input" style="display: block;">
		           	<span class="help-inline">Nom : </span><br/>
		           	<input class="span6" type="text"/>
		        </div>
	        </div>
	       	<div class="clearfix">
				<label>Prénom : </label>
				<div class="input" style="display: block;">
		           	<span class="help-inline">Prénom : </span><br/>
		           	<input class="span6" type="text"/>
		        </div>
	        </div>
   	       	<div class="clearfix">
				<label>Email : </label>
				<div class="input" style="display: block;">
		           	<span class="help-inline">Email : </span><br/>
		           	<input class="span6" type="text"/>
		        </div>
		    </div>
		    <div class="clearfix">
				<label>Naissance : </label>
				<div class="input" style="display: block;">
		           	<span class="help-inline">Naissance : </span><br/>
		           	<select class="small" name="mediumSelect" id="mediumSelect">
		           		<?php for ($i = 1; $i <= 31; $i++) { ?>
		                <option><?php echo $i; ?></option>
		                <?php } ?>
		             </select>
		             <select class="medium" name="mediumSelect" id="mediumSelect">
		           		<?php for ($i = 0; $i < 12; $i++) { ?>
		                <option><?php echo $mois[$i]; ?></option>
		                <?php } ?>
              		</select>
              		<select class="small" name="mediumSelect" id="mediumSelect">
		           		<?php foreach ($annees as $value) {
		                	echo "<option>".$value."</option>";
		                } ?>
             		 </select>
		        </div>
		    </div>
   	       	<div class="clearfix">
				<label>Nouveau mdp : </label>
				<div class="input" style="display: block;">
		           	<input class="span6" type="password"/>
		        </div>
		    </div>
   	       	<div class="clearfix">
		        <label>Confirmation : </label>
				<div class="input" style="display: block;">
		           	<input class="span6" type="password"/>
		        </div>
		    </div>
		    <div class="clearfix">
		        <label>Signature : </label>
				<div class="input" style="display: block;">
		           	<textarea style="resize: none;" class="xxlarge" rows="5">valeur signature</textarea>
		        </div>
		    </div>
		    <div class="actions" style="margin-top: 40px; margin-bottom: 0px;">
		    	<button class="btn primary">Enregister</button>
		    </div>
		</form>
	</div>
</div>